Mainline wants to make harm reduction more accessible to people who use stimulants. Unfortunately, many harm reduction projects still focus on people who inject drugs and use opiates.

In 2022, Mainline worked with SCDI to strengthen the stimulant learning hub in Hanoi. This is valuable work, as there is interest throughout the region in harm reduction for people using methamphetamine. In addition to a range of practical interventions to reduce the harm of frequent stimulant use, organisations in Southeast Asia are particularly interested in the community mental health approach we developed with SCDI. Now that the year is over, we are ready to share the knowledge we have accumulated with other harm-reduction organisations. This can be done through a visit to Hanoi, through our blended learning offerings, or simply by contacting us and exchanging knowledge.

The year 2021 was one marked again with uncertainty. Fortunately, throughout its 32-year history, Mainline has always found ways to conjure up new, creative ideas under pressure. And 2021 was no exception, with new and exciting projects established both at home and abroad.

Our focus this year was largely on young people, women and people who use drugs during sex. And for the work entailed, we relied increasingly on peer mentors who are keen to lend harm reduction support rooted in their lived experience. Youngsters like these know just how vital it is to be supported by someone who understands exactly what you’re going through and is able to connect with the person behind the behaviour or circumstance.

It took considerable effort to make the budget work this year, and not only on account of setbacks related to the pandemic. But we also mastered some new working methods, proved our worth in several countries around the world and developed a long-term vision on learning, training and the sustainable transfer of knowledge. A handful of beloved colleagues left Mainline in 2021, but we also welcomed some fantastic new people to the team, not least our chairman Wim van den Brink. And through everything, we remained an active presence in the lives of people who use drugs, as we shall continue to be in good times and bad.

We hereby present to you our annual report for 2021. Hope you enjoy the read!

The Mainline team

Mainline celebrated its 31st anniversary in 2021, and if there’s one thing that stretch of time has taught us, it is that experience matters. Experience helps you separate the signal from the noise. It helps you know your way around. And it lends you the authority required to be taken seriously. 

The same holds true for peer mentors. People with experience of substance use can employ that experience to help others. And in helping others, they heal from the traumas of their own past and regain a measure of independence and freedom.

In 2021, we launched our Peer2Peer pilot project, involving young adults with a lived experience of drug use. The objective of this FNO-financed pilot is to improve our effectiveness at reaching young people who use drugs and provide them with useful information on the matter. The individuals in question are aged between 18 and 35 and burdened by multiple challenges, such as homelessness, debts, a tendency to get into fights and mental health issues. We’ve already learnt an incredible amount from this project, and it is scheduled to run until well into 2022. The most important outcome thus far: findings that support our plan to deploy peer mentors in a structural manner for the support of other categories of people who use drugs.

The year also saw us develop our manual on “reducing harms in the work environment” into a series of training courses in South Africa. Working in collaboration with the South African Master Trainers, Mainline trained several groups of peer mentors and harm reduction workers across South Africa. The goal was to determine how the working conditions of colleagues who use drugs could be improved. We also managed to integrate the recommendations from the manual into their daily work. Participants completed a video assignment through which they provided concrete tips and feedback to their employers. This work was supported by the Centres for Disease Control in South Africa, through The Foundation for Professional Development.

In 2021, Mainline continued to advocate for the rights of women who use drugs, an endeavour that remains of vital necessity. Our study of the circumstances of female drug users in South Africa — findings of which we published in a report entitled Sister Spaces — yielded irrefutable evidence of the unattainability of the most basic necessities of life for countless women. 

According to the women with whom we spoke, these necessities include food, clean water, shelter and protection from violence. Life is not just tough for women living on the streets, it is also plagued by the ever-present threat of physical violence, harassment and intimidation. Informed by our findings, we drew up a list of recommendations and provided training to harm reduction services in five cities across South Africa. None of this would have been possible without our local partner Master Trainers, who played a leading role in conducting the study and delivering the subsequent training. Aside from harm reduction providers, we also trained several other organisations that are ideally placed to be of help to women who use drugs. These include shelters, women’s refuges and organisations that provide assistance with basic necessities. This work was also supported by the Centres for Disease Control in South Africa, through The Foundation for Professional Development.

No one understands better than our Kenyan partner MEWA how often women who use drugs are subjected to violence. The report Understanding Experiences, published in early 2021, offered a detailed and in-depth account of this phenomenon. The perpetrators of this gender-based violence were found to be a varied lot: partners, clients, family members and in-laws, people in the community, the police and more. Informed by the findings of the research, MEWA expanded their services for women within the framework of their harm reduction programmes. A positive performance evaluation of these efforts was published towards the end of 2021. Thanks to its clever lobbying strategy, MEWA also managed to secure better policies and regulations regarding gender-based violence and facilitate better access to sexual rights. This work was made possible by the International Treatment Preparedness Coalition (ITPC) through a programme funded by the Robert Carr Fund.

Mainline used its experience in South Africa and Kenya to inform a study of female drug users in Tanzania conducted via the Global Fund. The study included a survey in which we spoke with the women about their access to harm reduction programmes and healthcare services, and about any additional support they required. Here, too, we learned that women have barely any access to basic necessities and receive little to no suitable healthcare support for themselves or their children. We hope to use the report resulting from the study to draw attention to the plight of this group of women so as to secure their inclusion in services and policies as a matter of urgency.

Unfortunately, women who use drugs are also often overlooked in the Netherlands. Thanks to the familiarity and experience acquired over many years of providing services to people in the chemsex scene, we were able to make serious inroads with women who use drugs in a sexual setting. The women we spoke to in the course of conducting an exploratory study often reported having a whale of a time when they combined drugs with sex, but we also heard accounts of serious physical and mental health issues. The study yielded a fairly comprehensive picture of what results from the use of drugs in a sexual setting, primarily characterised a sense of deeper connection, an intensification of pleasure, a lowering of inhibitions, but also a higher likelihood of transgressive behaviour and non-consensual sex.  

Mainline devoted a great deal of attention to young people in 2021. We’ve already mentioned our Peer2Peer initiative, the outreach project involving young adults with a lived experience of drug use. 

Well, the same mentors were also invited to assume much of the responsibility of putting together a special themed edition of Mainline magazine. The issue covered subjects such as designer drugs, coping with mental health issues, the use of nitrous oxide, the difficulty of distinguishing hard drugs from soft drugs, and severe hangovers.

Working within the framework of the “Young, Wild and... Free?” project, Mainline provided structural support to two partners in Kenya and South Africa in setting up a pilot service aimed at young people. In implementing the project, MEWA, our Kenyan partner, identified a high incidence of severe mental health problems among young people who use drugs. These individuals reported an urgent need for improved access to harm reduction services. In addition, 17% of them reported seeking mental health support. MEWA published a report of their findings, and Mainline worked with the organisation to develop a training programme aimed at establishing the service both as a core offering and beyond the organisation itself.

In South Africa, TB/HIV Care ran a pilot scheme aimed at improving access to harm reduction services for young people. In Durban, this included experimenting with new outreach strategies, adapting existing services to the needs of young people and running support groups. There are lots of ways in which to assist young people at risk, such as providing the support they need to remain in school, avoid criminal activity or even becoming homeless.

The results of the Aidsfonds-led “Young, Wild and... Free?” project are available on the website www.communityharmreduction.com/youth, which includes all of the outcomes, key resources, and meaningful and actionable reports and findings related to working with young people who use drugs. The project was funded by the Dutch Ministry of Foreign Affairs.   

Mainline has been working for decades to make harm reduction programmes and practices more accessible to people who use stimulants. But unfortunately, most harm reduction programmes are still aimed primarily at people who inject drugs or use opiates.

Fortunately, our publication of the Speed Limit report in 2018 allowed us to offer multiple illustrations of innovative harm reduction programmes designed to support people who use stimulants. Much work on this issue has also been done in Vietnam. Since 2019, Mainline has been working with SCDI, our partner in Hanoi, to establish interventions for people who use meth-amphetamines, and mainly do so by smoking it. The results of this partnership include the “Stimulant Field Lab”, a regional learning hub that serves local organisations hoping to offer stimulant harm reduction services.

In 2021, we also offered a series of interactive webinars for programme managers, outreach workers and other frontline staff, with the aim of sharing experiences from Vietnam with other organisations in the region. Later in the year, we built upon this effort by working in collaboration with SCDI to launch the initiative to provide harm reduction services for people who use meth-amphetamines. Our goal is to improve the community-rooted response to mental health issues. We also aim to offer blended learning training packages that can be readily accessed by partners in the region. In addition, we’d like to boost the training capacity of the Stimulant Field Lab and organise field visits to the hub. These activities are all ongoing until the end of 2022.  

Mental health was top of the agenda for Mainline in 2021. It also remains a priority in our efforts in Vietnam, where we set up a low-threshold intervention rooted in the community and delivered through outreach workers. 

MEWA’s study in Kenya also revealed mental health as a matter of urgency for young people who use drugs, and Mainline subsequently provided the organisation a series of training sessions on the subject. MEWA’s Master Trainers then passed on what they’d learned to several other local organisations in the field.

Mainline also began training the staff of the Andrey Rylkov Foundation in Russia to enable them provide better help to people struggling with mental health issues. We sincerely hope that all the uncertainty and potential hurdles of 2022 will not get in the way of this work.

In Indonesia, we worked on the issue of mental health in closed settings. Atma Jaya Catholic University conducted an implementation study and introduced motivational interviewing in two prisons. The latter is an evidence-based method of stimulating positive behavioural change on the basis of intrinsic rewards. The effort proved a success, both in its effectiveness and in its cost-effectiveness relative to the usual “therapeutic community” approach to improving the health of people who use drugs in prison. On the basis of its findings and experience, the university subsequently developed a comprehensive set of guidelines and a training course for prison staff, and all indications are that motivational interviewing will shortly become the norm in other prisons as well. The work was a culmination of a whole series of studies conducted in prison settings, all of which were made possible by the International Treatment Preparedness Coalition (ITPC) through a programme funded by the Robert Carr Fund.

Finally, in the Netherlands, we published a wonderful special issue of Mainline magazine on the subject of trauma. This is quite an important subject, because as many as one in three people with a problematic drug habit suffers from post-traumatic stress, sometimes without even knowing it. The issue contained several personal accounts, dug into the subject of self-medication with drugs, and examined the accessibility of trauma treatment for heavy users. While such treatment is more accessible today than it once was, many obstacles remain.

Drug use in sexual settings is one of Mainline’s particular areas of expertise, and we were as active as ever in this regard in 2021. Among the outcomes of our efforts in this area was the publication of a Slamming Report, of which we are truly proud. 

It came five years in the wake of our previous major publication on the issue, Tina and Slamming; this time, however, we focused on new trends in the Dutch chemsex scene. We were pleased to note the high level of interest in our work in this area as evidenced by the number of professionals who tuned in to the webinar we hosted so as to share our findings.

In 2021, 111 participants attended our (online) chemsex meetings for men who want to stop or have stopped engaging in chemsex. Of these, 26 were “new” (unique) visitors. We also saw a rise in the number of men attending chemsex consultations this year, and they came from across the country. A total of 184 people contacted us for individual consultations with our outreach workers. We also noted a rise in the number of friends and family members of users as well as professionals from various disciplines in need of information, advice and support. There was also a notable spike in the number of serious incidents. These included visits to the emergency room, involvement in traffic accidents while under the influence, commissions of transgressive sexual acts, blackouts, chemsex-related deaths and suicide attempts.

Our two chemsex experts gave presentations at the first edition of the Chemsex conference in Oslo, organised by the Norwegian organisation Chemfriendly. And our intern Valerie wrote a report on the lack of appropriate support for people experiencing both sexual and drug-related problems.

Mainline was frequently approached to collaborate on chemsex-related projects by organisations the world over. In Georgia, we worked with the Doctors of the World (MdM) team to establish various chemsex interventions. This included a capacity building programme consisting of a needs assessment and online training. We also worked with various organisations in Eastern Europe and Central Asia to expand the harm reduction offerings for men in the chemsex scene. In 2020, Mainline teamed up with ReShape/IHP (UK), AFEW international and the Humanitarian Action Foundation (Russia) to organise a pair of knowledge-sharing sessions with ten further organisations from five countries. We subsequently used the insights from these discussions to develop an online training series for participants from the region, and hosted the first training session in July 2021.

Spurred by the rise in interest from organisations around the world, Mainline set about developing a chemsex e-learning course geared specifically to health professionals. The course has now been taken by more than 50 such professionals.
Researchers Laura Nevendorff (Indonesia), Theresia Puspoarum (Indonesia) and Doan Thanh Tung (Vietnam) put together a comprehensive manual on chemsex in Asia. You can read Mainline’s digital summary of the document here: www.communityharmreduction.com/chemsexinasia

As is the case each year, Mainline received frequent requests to go on location in order to paint a picture of the local drug scene. This has been a regular offshoot of our fieldwork in the Netherlands for decades.

In 2021, the undertaking took us to over 30 cities and 80+ organisations, and we spoke with over 1,000 people who use drugs as well as with 378 professionals who work in social care, drug consumption rooms or healthcare institutions.

But Mainline was also asked to map the scene in other countries. In Zambia, for instance, we were asked to estimate the size of the population of people who inject drugs in three cities. We also evaluated this population’s access to healthcare, and suggested ways to improve existing provisions. On the basis of our findings, we put together a step-by-step guide to harm reduction with lots of tips and policy advice to help lay a solid foundation for this service in Zambia. This work was funded jointly by the UNODC and the UNDP.

The UNODC office in Iran asked Mainline to evaluate the harm reduction services in Tehran. We began with desk research. Then, working with a local researcher, we organised two training sessions for a group of students and harm reduction workers so as to familiarise them with the research methodology we intended to employ for data collection. Unfortunately, the actual execution of this research was delayed by the pandemic, but we hope to finish the job in 2022.

Working within the Love Alliance programme, Mainline teamed up with the South African Network for People who Use Drugs (SANPUD), who asked us to conduct a 10-country study of the state of affairs regarding drug policy, infectious diseases, human rights and access to harm reduction services for people who use drugs. We fed the data from this study into a user-friendly database that can be employed to increase the success rate of lobbying efforts aimed at improving the well-being of people who use drugs. This project was funded by the Dutch Ministry of Foreign Affairs.

Access to harm reduction services is crucial for people who use drugs, but it is equally vital that such individuals be free of the constant threat of arrest simply for using drugs. 

A growing number of countries are opting to decriminalise the use of drugs; in other words, they are starting to exclude the possession of drugs for personal consumption from the scope of criminal law, as is the case in the Netherlands.

There are several advantages associated with this policy. These include saving vast sums of money by reducing prison costs, preventing human rights violations and enabling the provision of healthcare services to people who use drugs. However, the actual implementation of this policy has been found to vary greatly from country to country. As a result, Mainline teamed up with IDPC, Frontline AIDS and the Health[E]Foundation to develop a free online course that takes decriminalisation advocates through the best practices to follow at each stage of the process. Advocates can register for the course whenever they choose and follow it at their own pace.

As usual, we published four themed issues of Mainline magazine during the year, and for the first time ever, we devoted an entire issue to people under the age of 35. But what was truly novel about this issue was that we handed over much of the content-related decisions and execution to our volunteer team of young peer mentors

The theme in this instance: the difficulty of distinguishing hard drugs from soft drugs. The issue also covered subjects such as designer drugs, coping with mental health issues, the use of nitrous oxide, fact checking and severe hangovers. We also published an issue on the subject of trauma. One in three people with a problematic drug habit have been found to suffer from post-traumatic stress, often without even knowing it. The theme of our first issue of the year was polydrug use, and it included an exhaustive overview of safe and risky combinations. The final issue was about home use, a timely theme to round off a year defined by a pandemic. 

We also published four dedicated double editions during the year. We often find during fieldwork that current and past issues of our magazine are perfect tools for breaking the ice with people we seek to engage in conversation. And it really helps that we’ve addressed so many themes. Of course, certain themes attract more interest than others, resulting in certain issues of the magazine selling out faster than others. To address this, we put together composite issues of our most popular articles on alcohol & snorting, opiates & base coke, speed & weed, and sleep & mental health.

Finally, we updated several of our brochures, including Slamming: Do’s & Don’ts, which provides practical information on slamming techniques, safer use and managing the after-effects of slamming sessions.

We also helped our South African partner NACOSA develop a series of educational materials covering subjects such as opiate treatment, hepatitis B and C, women who use drugs, and overdose prevention.

We expanded our training portfolio in 2021. For obvious reasons, several of our courses had to be delivered virtually, but this actually had its benefits, such as forcing us to streamline our online and blended learning packages. 

We ran a total of 77 courses during the year, 47 of which were delivered virtually. The training recipients were industry professionals (including healthcare professionals) from 26 different organisations, which included social care facilities, hospitals (including academic hospitals), municipal health centres (GGDs) and mental health clinics (GGZs). The subjects of the courses varied from Dealing with GHB use in Social Care Facilities and Chemsex to Drugs & Mental Health and Establishing Contact and building rapport with Clients. We also created an entirely new page on our website so as to better present the contents of our training portfolio.

Despite the pandemic, we also managed to organise several virtual and in-person training sessions and presentations on chemsex. These included sessions and presentations on behalf of GGD Hart voor Brabant, GGD IJsselland, GGD Haaglanden, NVVS, addiction clinicians in training (at Radboud UMC in Nijmegen) and the Jellinek Outreach Team. We also ran a handful of open courses during the year, something we hope to do more of in 2022.

We’ve already mentioned the courses we ran abroad, including those delivered through Master Trainers, with whom we work quite frequently. These individuals are all qualified harm reduction trainers who have successfully completed our train-the-trainer programme. The training they deliver is usually part of a larger project, and as a result often helps ensure the overall effectiveness of these projects. Our strong track record in 2021 has inspired us to aim even higher in 2022. Not only do we intend to offer more of our training as hybrid and blended courses (in-person sessions accompanied by real time or asynchronous online activities), but we’d also like to start working with learning pathways and find seamless ways to embed training in fieldwork, research and policy consultancy, both in our work at home and abroad.

Setting up a new museum is no walk in the park at the best of times, let alone in the middle of a pandemic. And it was clear that we would need lots of public support in the form of high attendance figures to demonstrate the feasibility of a drugs museum once it opened. 

So the fact that we did not manage to secure a permanent location for Poppi, our museum, in 2021 was actually a stroke of luck, as it allowed us to wait out the pandemic and resulting lock-downs. But finally, towards the end of the year, we had the pleasure of welcoming everyone to the Worlds of Opiates, a pop-up museum in one of the passageways running through Central Station in Amsterdam.

The museum was a collaborative venture between Poppi, Utrecht University, artist Corne van der Stelt and Het Uitvindersgilde (the inventors guild). The exhibition within was an informative exploration of the history and use of opium, laudanum, morphine and heroin, and of some of today’s more commonly used painkillers, such as tramadol and oxycontin. Visitors were taken on an interactive journey in which opiates appeared in their various guises, evoked different and changing opinions from officials and the general public, and found different uses over the course of time.

In addition to the exhibition, we also redesigned Poppi’s website and completely rewrote our museum business plan. The new year promises to be an exciting one for Poppi, with events and ambitions including the opening of an audacious pop-up store “The XTC Shop” (open from 15 July to 29 September), the unveiling of a pretty exciting online plan and hopefully the establishment of a permanent location.